Provider Demographics
NPI:1508833146
Name:WILSON, JOHN TYLER IV (CRNA, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TYLER
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:CRNA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 WILLOWCROFT CT
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-6278
Mailing Address - Country:US
Mailing Address - Phone:808-295-6256
Mailing Address - Fax:
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-6286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC072006367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered